A while back, I gave an EKG challenge to the blog-o-sphere to review an EKG of a young man who presented to the Emergency Room for evaluation of shortness of breath and lightheadedness unrelated to exertion. After posting the EKG, I got all kinds of answers for the young man's ailment, but most failed to guess the gist of the exercise: that the EKG was normal.

It is interesting to ponder why.

In medical school, we are trained to develop a differential diagnosis to any and all symptoms before us. Heck, I can remember the pneumonic "VINDICATES" that allowed me to spew forth such great diseases caused by vascular, infectious, neoplastic, degenerative, iatrogenic, congenital, autoimmune, traumatic, endocrine or neurologic ("squash") causes for virtually any unusual finding on a chest x-ray or lab test. It's how we were trained. Think of everything. Don't you dare miss anything, lest you be judged incompetent in the Court of Public Humiliation on rounds with your Chief Resident or Attending. Cover all the bases. Your patient depends on it.

More senior and experienced attendings usually performed the same exercise, albeit at lightning speed. They quickly consulted their vast experiential database to prioritize the most likely diagnosis, leading to a razor-like ability to hone in on the problem and affect proper treatment. Nine time out of ten they were right on, and we stood in awe. Years ago, that was good enough. Attendings were appreciated for their remarkable accuracy but permitted the professional courtesy of occassionally missing a diagnosis. Naturally as residents, we relished the moment when we got it right when the attending didn't: those cases were always presented as "The Case of the Week" conference on Fridays where we rehashed the play-by-play of our diagnostic acumen. It was how we learned.

But with the evolution of the information era, the remarkable improvements in radiologic image quality and test performance, and the speed with which those images and test results are acquired and reported, deductive reasoning and judgement in our Emergency Rooms and offices based on careful history and physical examination has given way to a plethora of testing. God forbid you miss something. Better to shot-gun it rather than limit it. It is far easier to explain a negative test finding than a missed diagnosis. But what about the unexpected findings of, say, a positive troponin from a person with an inflamed toe from gout? Should a cardiologist be consulted? What are the risks to the doctor if there is a heart attack underway?

With the constant drumbeats of "quality" and "safety" echoing in doctors' heads coupled with shortened office visits and overriding liability concerns, a psychology of professional protectionism has come to trump judgement. There simply is no reward for proper judgment in our system, even though there are lots of reasons for false positive troponins. But it is difficult to explain this to a concerned patient and only huge financial and emotional downsides if you're wrong.

So the cardiologist is consulted, the echo obtained, and the nuclear treadmill performed, even as our judgment tells us otherwise.

It's just too risky to do otherwise. After all, it only takes one subpoena.

But as we limit doctors' salaries, drug costs, restrict certain testing (as much as we can), and limit hospital stays as much as we can through policy after policy, we must ask ourselves why we consistently fail to limit liability as the costs continue to spiral ever higher.

"Even in decent economic times, Illinois was not a state that funded people with developmental disabilities to the extent that other states have," says Lilia Teninty, director of the state's Division of Developmental Disabilities.

Illinois came in dead last -- 51st -- among all states and the District of Columbia in providing small residential settings for people with developmental disabilities. In terms of overall spending for community programs, it ranked 43rd.

Community Link hasn't been paid by the state since July for many services. Mr. Foppe and his staff whittled budgets, eliminating small bonuses, rug cleaning and renovation plans.

This crisis is made even more acute by the advances in medical care that have permitted children with severe developmental disabilities to outlive their parents, forcing many to receive care in larger institutional settings far from their own communities.

But there always seems to be money to build big buildings in our state. Especially big hospital buildings. One only needs to look down the road at SIU's SimmonsCooper Cancer Center in Springfield, IL which opened to great fanfare in July of this year, but:

"... the facility will not begin serving patients until late fall or early next year because of money cut from the state budget proposal for fiscal year 2009."

With such an 8-year construction albatross sitting empty in one of the more economically-depressed areas of the state, one wonders how deep the state is into construction of marble-lobbied health care facilities and political giveaways instead of funding critical basic health care and social needs in smaller, more meaningful venues.

Wednesday, November 26, 2008

It seems only fitting that in this time of Thanksgiving, we take a moment and reflect on things that really make a difference, some of which go unnoticed. While there are some things we all should be thankful for, I'd like to focus on my workplace this year.

For the doormen and doorwomen, who smile and say "hello" to my patients and help them get in their cars after being in the hospital. Thank you.

For the volunteers who staff Same Day Surgery and help point me to the family members of my patients so I can discuss the outcome of their loved one's procedure.Thank you.

For the cleaning staff, who tirelessly enter the offices, empty the trash, turn off the vacuum as doctors enter the patient's room, and do the million small things that make our workplace look so nice.Thank you.

To the cooking staff who go in the back to see if one of my favorite salads might still be available to purchase when none existed on the shelf, then find there are none, but make a new one anyway.Thank you.

To my 'Main Man' at the Coffee Shop who ALWAYS says "Have a good day, Doc."Thank you.

To my spectacular office administrative and secretarial staff, who greet me with a smile, politely coax me into complying with the administrative tasks you know I hate but must endure, for making my letters and reports look so professional, for answering the phone and helping my patients get what they need, and manage my entire hospital existence with professionalism and tact.Thank you.

To my cherished lab technicians, who get in early, set up the operative field just the way I like it, make sure the equipment is there and working, and show me some of the funniest tidbits on the internet I've seen in a while.Thank you.

To the lab nurses, who also get their early, greet the patient, reassure them, prep them, make them comfortable, serve up the pharmacologic drugs du jour so the patient always loves the experience, makes sure I document my "initial assessment" before scrubbing, and always make me look good.Thank you.

To the administration, who make sure we can turn on the lights, pay the staff, warm the hospital, tolerate this blog, and actually enjoy doing the 100 million regulatory and safety requirement things that would drive me crazy to implement.Thank you.

To the Information Technology department, for listening, improving, and somehow keeping the patient data flowing to me, endlessly try to make my job more tolerable despite the patient care documentation burdens to assure our payments.Thank you.

To my doctor colleagues, who stand with me as we do a tough case, share the call, help with the Holter, EKG, and event monitor readings, talk with my patients just as they'd talk with theirs, work their magic, and continue to have remarkable insights and suggestions to improve what we do every day.Thank you.

And finally, to my wife, who, despite all these years of hearing beepers go off at night has somehow managed not to say a disparaging word, ever.Thank you.

The current average biventricular pacemaker implant costs only $3,714 less than median personal income of the US in 2006 and exceeded the median personal income of people from 21 states in the union that same year.

(WSJ): "Health-care costs are creating financial problems that lead to housing problems," says Mark Rukavina, executive director of the Access Project, a Boston-based research and advocacy group on medical debt. A biennial survey last year by the Commonwealth Fund, a nonpartisan research group, found that 41% of about 2,600 working-age adults had fallen behind on medical bills, up from 34% in 2005.

It just makes sense: many people have been using their homes to finance their health care costs.

The question now becomes not if the housing market will affect health care, but by how much?

Monday, November 24, 2008

In medical school, I was always impressed that the sounds and smells of the operating room never accompanied pictures I'd see in text books. For the unititiated, these can take one by surprise. Although the smell of electrocautery cannot be captured in this video, the sound of the bone saw as it cuts through the sternum is recorded... loudly.

The book The Tipping Point by Malcolm Gladwell makes an interesting premise: that large sociological changes are usually hatched from small incremental events that, taken collectively, disrupt sociological behaviors. Such tiny events, when they occur frequently enough, build to create a "tipping point" that changes human behavior and disrupts market and sociological trends.

I couldn't help but think I viewed a "tipping point" when reading the excellent journalistic piece reported by the Boston Globe last week, entitled, "A Heathcare System Badly Out of Balance" that describes the complicated pricing differentials between large "name brand" hospitals and their competitors in the Boston healthcare market.

But what made the writing of this piece possible was one small event. A tiny disruptor. What was that tipping point?

Price transparency.

It was the ability to compare costs that permitted the revealing report:

The insurance data obtained by the Globe, drawn from millions of medical claims collected by the state Health Care Quality and Cost Council, is a byproduct of the state's sweeping healthcare reform law of 2006. Because some hospitals treat sicker people, the data has been adjusted to reflect the cost of care for an average patient.

The law calls for the council to post insurance claim information on the web so that the public can see the disparities.

But transparency, as the authors point out, was not easy to come by and verify.

But a year and a half after the law was passed, the council has still not published its findings because of disputes with medical groups about how the numbers should be presented and whether they are accurate in every detail.

"Apparently, this subject is the equivalent of the third rail," said Gregory W. Sullivan, the state's inspector general and a member of the Quality and Cost Council.

However, council officials say privately that the data, after months of review by the hospitals, is generally accurate. Partners said it has raised concerns "about the data and methodology" with the council. But other hospitals contacted by the Globe either confirmed the data's accuracy or would not comment on it.

It is important to realize that price transparency did not always change peoples' perceptions or actions (particularly if they did not have to pay for services through insurers). But for others with high-deductible insurance policies who bore much of the cost for tests themselves, price mattered.

In the days ahead as policy makers meet to hash out details of our new health care strategy for the future during these harsh economic times, insisting on verifiable price transparency from all parties will serve as a powerful incentive to improve quality while reining in costs to the ultimate health care consumer: the patient.

Friday, November 21, 2008

Without making any representations about the relative clinical value of this robotic system versus manual laparoscopic surgery, I am writing to let you know we have decided to buy one for our hospital. Why? Well, in simple terms, because virtually all the academic medical centers and many community hospitals in the Boston area have bought one. Patients who are otherwise loyal to our hospital and our doctors are transferring their surgical treatments to other places. Prospective residents who are trying to decide where to have their surgical training look upon our lack of the robot as a deficit in our education program. Prospective physician recruits feel likewise. And, these factors are now spreading beyond urology into the field of gynecological surgery. So as a matter of good business planning, concern for the quality of our training program, and to continue to attract and retain the best possible doctors, the decision was made for us.

I took a brief blog break to update our MedTees site to get ready for the holidays. If you haven't seen it, head on over and check it out.

MedTees, humorous t-shirts for the irreverent patients out there, make a great gift for folks who've had a tough year medically and help support a variety of charitable organizations. This weekend, free shipping is available for orders of $50 or more (just be sure to enter the proper coupon code a checkout). We ship internationally, too.

I really don't like it when policy wonks use the term "stakeholder" in the health care debate.

I mean, what do they mean? Do they mean someone holding a stake?

Or maybe it's someone holding a steak, and they just misspelled the term.

I suppose we all know what a stakeholder is: it's someone who has a "stake" in making a profit monetarily from our health care system. As such, the term really has nothing to do with patients, since patients are always the one's paying the for the big, juicy 64-ounce porterhouse "steak" that health care has become.

You see, "stakeholder" is a business buzzword, and make no mistake, health care is business, America. Big business. And Big Business wants what's best for you - really - just so long as they get their piece first. Rest assured that the back-room dealings in our non-transparent system will assure that they will continue to adjust prices to assure their profits, paying themselves first and justifying payment costs to the doctors and nurses ultimately responsible for your care in turn. That's the way business works - they MUST respond to their shareholders - those with a financial stake in their business - before they respond to their customers. For viability, business interests must always come first.

So who are these "stakeholders?"

The Insurance Companies

Insurance companies are powerful players in the health care debate. This is not to say that insurers are not important to future health care policy. On the contrary: insurers can play a vital role at making health care affordable to many by spreading risk across many contributors. But insurers do not currently modify their practices based on the individual policy holder's needs. No, insurers answer to the individual's employers, and regrettably a conflicted intermediary is born: one who wants to limit costs and bids on behalf of their group of patients, rather than individual preference or need.

The Employers

Employers are the next big "stakeholder" in the health care debate. They feel they have to pay the bill. At least they did. Suddenly, with the increasing costs associated with health care, they're finding harder than ever to offer health insurance to their employees. They know that without insurance, they might be placed at a competitive disadvantage when recruiting new talent for their company if this benefit is NOT offered. So they succumb to market pressures, and offer a policy that will be affordable, yet just accommodating to the majority of their employees. Lately, these policies shunt more of the costs to the employees themselves.

Hospitals

But the complexity (and "stakeholders") expands further. Hospitals compete for the large patient population of patients held by employers. They spruce up their facilities, increase their market footprint, and buy the latest gadgetry in a never-ending marketing push to secure more of the patient population under their care. There is a business imperative to be all-accommodating to patients and open, Walgreens-like, a clinic on every corner. With more patients, they drive a harder bargain with insurers, pointing to the high cost of doing business as rationale enough to justify their demands for higher payments from the insurers. Insurers, then, court the businesses, and fight negotiate with the hospitals until a price-point that will make both entities happy is struck.

The Pharmaceutical, Device, and Health Care Support Industries

The fight between hospitals and insurers would not be as brisk if it weren't for the high cost of consumables in health care. Drugs and devices are the easy entities to discuss, but one cannot overestimate the ancillary service industries that have sprouted to support the complicated billing-denial-payment collection cycle that is now commonplace in health care delivery today. Everyone gets a piece of the action. A new cardiac device supplants the old, without any real need, because it adds a new bell or whistle and market analysis says "it's wanted." We have over 75 drugs to treat hypertension, but only the latest and greatest are touted. Advertisers subsume the nightly news with their commercials asking the public if they've talked to their doctor about erections lasting four hours. It's crazy.

You

Meanwhile, the patient is paying the bill for this expansion and market positioning through higher insurance premiums, higher deductibles, and higher cost markups that appear on their health care bill.

With our most recent election, our health care funding crisis began to surface as a critical issue. Americans voted for "change." But so far it appears we're going to get more of the same when it comes to health care, simply because the system of third parties remains intact. In its current iteration, it appears now another layer of bureaucracy is being envisioned: a board modeled on the Federal Reserve to “offer a public framework within which a private health-care system can operate more effectively and efficiently — insulated from political pressure yet accountable to elected officials and the American people.”

What?

The only real objective "change" I have heard discussed has been an overt shift of Medicare payments from specialists to primary care to support the primary care troops.

Okay. I'm game. Socialists principles are applying. I get it.

But employers will still be paying for their employee's insurance, insurers will still be bickering with hospitals and courting employers, hospitals will still be growing their networks and facilities, and the patients will still be paying all of the costs, except now some of those costs will be conveniently disguised as our national debt.

In essence, we seem to have a bunch of plate-spinning going on here by the steakholders stakeholders of health care that does absolutely nothing to address the cost crisis we have in health care today. Unfortunately, because stakeholders really hold the money to affect change, it seems unlikely there will be a move for self-introspection: rather, they all have to compete with each other as government funds the spending orgy. Doctors and nurses are increasingly employees of hospitals and the AMA is funded by and as such have lost much of their bargaining power in the debate.

And so, from the 50,000-foot view, patients will ultimately be left holding the financial bag, unless somehow, some way, we wrestle control of our own money from that of the third party stakeholders and assume responsibility for our own long-term well-being and health. Structuring such a system would amount to real change.

How do Wellpoint (Angela Braley, President and CEO), Pfizer (James Kindler, Chairman and CEO), Mayo Clinic (Denis Cortese, MD, President and CEO), and Novartis Pharmaceuticals (Daniel Vasella, President and CEO) see fixing health care? Here are the talking points from the Wall Street Journal's CEO Conference discussing their priorities for the Obama administration (with a few of my thoughts in italics):

Use the "bully pulpit" to fix obesity.(Nice. Tell people to stop being fat. I'm seeing an efficient use of resources here, aren't you? And clearly this job is too difficult to take on themselves: make this the focus of the surgeon general and be sure to increase the PR spin about obesity.)

Tort Reform - use the vaccine model to reduce malpractice.(Best of luck. Remember, it's the lawyers who write the playbooks.)

Define and Measure Value - define and measure desirable outcomes for most common diseases(Look for more check lists and "quality measures" to be tracked)

Payment Reform - Reward preventative care and evidence-based care (can you say more P4P?) and no longer reimburse inappropriate, unnecessary, or wasted care.(In other words, continue covert rationing efforts and care denials as well as renewed efforts to "discover" waste, fraud, and abuse in the system.)

And when asked to "rank their priorities" of how to begin, we find that health care reform is (fortunately) way below the economic stimulus efforts underway. But when pressed on setting priorities for the new administration, they recommended the following:

Define value, reform payment as their initial focus.("Value?" Value to whom? The Insurers? Pharmaceutical Industry? Hospitals? The Government? Or are we really talking about patients here? What does "value" mean when the term is used with CEO's with such varied biases? I suspect that payment reform is more the real goal here: basically pay providers less and let Americans continue to shoulder more of the health care dollar. If not, what specifically does this mean? Could we PLEASE stop the spin?)

Next, tort reform.(This would be nice, but why have prior efforts failed? Will plaintiff's lawyers agree to caps on damages? If so, how much?)

Fight obesity.(Sorry, but to spin this as the way to cut health care costs seems disingenuous. Like this is an easy issue to fix. The psychologic and sociological issues surrounding obesity are WAY to complex to suggest that government can fix this problem. Are Starbucks, Panera, Burger King, McDonalds, and every gas station quick-mart going to just sell salads and whole grains? I don't think so. Certainly, some help with EDUCATING the populace is always important, but as it is, I've never met an obese person who wasn't aware of their problem and wouldn't prefer to be skinnier. While noble in intent, practically I find this effort a distraction to fixing our health care crisis. After all, people MUST eat. They DON'T have to smoke. What about banning ALL tobacco products and tax the heck out of alcohol? Why not stop all pharmaceutical and medical device advertising tomorrow to SAVE MONEY? These measures would save billions instantaneously without one bit of downside to the populace. Heck, the evening news might even be nice to watch again...)

Finally, build the health care work force.(Let's see, it takes four years for medical school after college and two years for nurses... look for ancillary health providers to play an increased role in health care delivery. There is no question that more efficient care and information transfer can exact huge savings, but that government will have to step up to equip our health care network with the equipment to do so.)

There's lots of low-hanging fruit that can be addressed to begin to fix health care today. It's nice to know that corporate America is trying to struggle to address these issues. But I always find it interesting that when health care is the issue, government reflexively turns to corporations with their own vested interests to shape policy, rather than turn to the front lines for answers.

"...the states are expected to face significant budget shortfalls in the coming year as a result of the weak economy. The last time the states faced budget shortfalls, they cut funding for tobacco prevention programs by 28 percent between 2002 and 2005. The cutbacks are a major reason why smoking declines subsequently stalled..."

Talk about "spreading the wealth." I just hope it's not short-sighted.

Monday, November 17, 2008

(Medscape - subscription required) "As cardiologists' income has been declining, we've seen a trend toward adding ancillary services," says Patrick White, president of MedAxiom, a cardiology practice management and information services firm in Neptune Beach, Florida. "I've seen cardiologists starting to do laser vein therapy and selling vitamins," says White. "But these are likely to divert their energies. Instead, they should focus on their core mission."

In 2007, the median total medical revenue for cardiology practices decreased 0.61%, while median operating costs increased 6.3%, according to the Medical Group Management Association's (MGMA) 2008 Cost Survey Report."

As specialists are threatened with declining revenue streams as our government Robin Hood compadres shift payments from specialists to primary care in the interest of "lowering costs," why aren't hospitals who have profitted handsomely from the high-tech procedures performed by specialists stepping up to stem the bloodletting?

I believe it's because the model for primary care medicine has changed dramatically over the last five to ten years. Primary care, as we know it now, isn't the all-encompassing primary care model that it once was in years gone by. No longer is it the norm for a primary care doctor to follow their patients in the hospital. Regretfully, the payments to doctors for the time spent have dwindled to the point where doctors have to stay in their offices to treat more and more patients in less and less time and resort to turning over their soon-to-be inpatients to "hospitalists" to manage them in the hospital.

They are turned over today to young, eager, relatively cheap hospitalists fresh out of their internal medicine residency. The same hospitalists who are often hired by hospitals because they order lots of tests and decrease the patient's length of stay. The same hospitalists whose salaries are typically subsidized by the hospitals. And the hospitals are eager to keep their hospitalists happy because they need even more consults and tests performed whose technical revenues exceed professional revenues by about ten to one.

Physician salaries are a relatively small piece of the health care cost pie.

So shifting payments might be a pretty good return on investment for hospitals: watch the specialists' salaries decline and shift funds to the hospitalists (your employees or employees in proxy) as you earn more for them and lots more for you.

I guess that's why they're in business and I'm in medicine and hospital leadership can gloat over a $2.25 million a year in a place with relatively low cost of living, justifying that income because "I'm a poor kid from a mill town. My father graduated from high school, and my mother didn't. And so it is a lot."

Sunday, November 16, 2008

"The Baucus plan would seek a continued focus on the high value of primary care-related services, with corresponding reductions in relative values for overvalued services."

"To avoid cost inflation, this proposal should be made budget-neutral. Budget-neutral changes to Medicare payments mean that any increase to primary care providers requires a corresponding cut to specialist services. This approach has the potential to create significant controversy among physicians, however. Any reforms along these lines must be crafted in collaboration with the entire physician community and other practitioners to ensure appropriate valuation of, and access to, primary care services."

Any appreciation for one's skill level and years of experience: overvalued.

Requiring five additional years of subspeciality training: overvalued.

Being paid well below what generalists were making during those five additional years of training: overvalued.

Requiring two more recertifications every 10 years and the expenses incurred for continuing medical education credits to permit sitting for those boards: overvalued.

Performing truly curative procedures, rather than palliating them with medications for a person's lifetime: overvalued.

Being paid the same for a four to five hour case as a two-hour case: overvalued.

Focusing on the already-failed experiments of PQRI and "wellness" and "preventative" initiatives that have bloated our bureaucracy and failed to have any positive return on investment: undervalued, so please, let's do more.

Yeah, I see where this is going...

-Wes

P.S.: Could someone explain to me why the good Senator's white paper sounded so much like the one from these guys?

Daniel Callahan explains his position on rationing health care for the elderly: is 80 years of age where we draw the line?

There are in the end only two decisive ways to control Medicare costs: raise taxes, cut benefits, or both. Neither political party is game to raise taxes, for Medicare or anything else. As for cutting benefits, Congress this year voted for $20 billion in new expenditures, ignoring the need for frugality.

Yet there is nothing of importance left to do other than to reduce benefits. That move would mean denying elderly patients both what they might want and need. Or are there some less draconian alternatives? A long-standing refrain of many older people is that much money could be saved if they were more easily free — by living wills or the appointment of surrogates — to turn down expensive life-prolonging measures of dubious benefit. Maybe so, but some studies have shown that would not make much economic difference in an overall Medicare budget of hundreds of billions.

More important, despite what they say in advance, many elderly people will in fact choose to be aggressively treated for a critical illness even when there is a good chance it will not save them — but just might. Doctors endlessly complain to me that excessive patient expectations of medical miracles, or those of their family members, make it harder, not easier, these days to curtail aggressive treatment. Not all of us can resist the lure of a slightly longer life, despite what we may have said in advance.

Ninety seems like a safer bet to be palatable right now than eight as an age limit, but his points are worth pondering.

Looking at the way the government is doling out money these days, I have a proposal to help improve people's health and our system of care. What if the government gave each person $365 of their tax money back to be spent on primary health care?

That amount could be paid directly to each person's primary care doctor for a year's worth of services. Imagine if everyone in America could contract privately for medical care for themselves with a primary care doctor without government or insurance company red tape.

The patient would choose the doctor. The basket of services would be predefined, and the price would be locked in for a year, paid as a monthly subscription like cellphone service or movie rentals.

Money spent that way would cover a lot of preventive health, office visits, management of chronic diseases, email contact with the doctor, and after-hours advice. Make it tax deductible for individuals as well as businesses.

Doctors like the idea of universal coverage, but don't like the idea of unfunded mandates, like some programs to improve quality that cost physicians more to implement than can ever be recouped.

They don't want to be conscripted into a national program that pays them less than their costs. They don't see Medicaid or Medicare for all as solutions because those systems skimp on primary care and impose crushing paperwork and regulation.

But it seems to me that it is time to get beyond the argument of whether health care is a right or a privilege. We need to do something practical to bring affordable, basic health care to working people. Primary care isn't cheap, but it's less expensive than any other option.

We have had a financial stimulus package. My patients spent their $600 checks on $4 gas to get to work. A better and longer-lasting use of the money would be a health-care stimulus package.

The attraction for the doctor would be no billing hassles, no massive insurance coding system, no extensive overhead, and no bogus pay-for-performance schemes that cost more than they save. The infusion of money would also bolster primary care and might make it more attractive to new doctors over the long haul.

For primary care doctors, a $1 per patient per day would make for reasonable income from a smaller group of patients than most of see now. Patients would get more time with their doctor when they need it. There would be fewer office visits just so the doctor can get paid for giving advice.

Is his idea so far fetched?

I don't think so.

And yet, make no mistake, the push back will be substantial from those who benefit from the bureaucracy.

I am aware that even large physician groups such as ours, already equipped with the latest electronic gadgetry to track pay-for-performance initiatives, in their zest to go "all in" on the concept to earn their "gold stars" on the government's pitiful quality website (which is rarely consulted by patients, by the way), failed to cover the cost of implementing the initiative its first year. It's been just too many personnel, spending too many precious resources to gather data of limited value, rather than applied to the delivery of health care. (If you want to see just how bad it's become, check out the specifics over at the Happy Hospitalist.) This initiative has been a colossal failure in my book, but sold lock, stock and barrel to the populous by the policy wonks on Capital Hill.

So I can hear it now: "What will happen to all of those people paid to collect the data? They might become unemployed at this time of our colossal economic downturn! Our unemployment numbers will go up! We can't have that!"

Please.

We cannot afford NOT to make a significant change to the way we do health care today. I am convinced as Americans consider the options ahead of them, that they'll make the right choice and realize the consequences if they don't. Dr. Brewer's proposal makes a lot of sense.

Thursday, November 13, 2008

But the popularity of "kids-free" communities also adds an interesting wrinkle to the debate over Illinois' school-aid formula.

Recent protests at two North Shore schools spotlighted the high property tax price that residents of some suburbs pay per student.

The housing shift is not confined to the Chicago area. A few years ago, officials in suburban Boston approved so many age-restricted developments that a state legislator decried the practice as "vasectomy zoning."

(Sorry, couldn't resist linking to this, but it's an interesting use of a medical term...)

This is in stark contrast to few brave souls from the blog-o-sphere who voted here:

For: 9(81%) &nbsp Against: 2(18%) &nbsp Precincts reporting: 100%

Officially, the tally in Arizona is still considered too close to call.

Hey, if American Express and GM (not to mention half the financial system in America) can ask for a government bailout, why shouldn't everyone tap into the bottomless well of the US Treasury to supply their health care needs also?

An interesting concept was presented at the American Heart Association in New Orleans today: a device that uses atrial and ventricular contractions to power a pacemaker:

The SIMM microgenerator is a catheter-mounted device that would be placed on a conventional pacemaker or defibrillator lead. The device harvests energy by using differential pressure within the chambers of the heart to drive a linear generator. During testing, the device generated one-third of the power required to run a pacemaker (excluding pacing demand). Next-generation microgenerator devices are expected to fully power both the pacemaker and pacing requirements. Placement of the microgenerator is uncomplicated and is fully compatible with existing techniques for implanting cardiac devices.

Using pressure responsive balloons within the right atrium & ventricle, advantage is taken of the pressures generated in the heart during the cardiac cycle to drive a reciprocating linear generator. In normal function, the atrium contracts first, compressing the atrial balloon & driving the generator mechanism in one direction; then the ventricle contracts, compressing the ventricle balloon & driving the mechanism back to its ‘starting’ position. The reciprocating movement of the mechanism generates the electricity used to power implanted devices.

"On October 24, 2008, we received a letter from the U.S. Department of Justice ('DOJ') informing us of an investigation relating to surgical cardiac ablation system devices to treat atrial fibrillation. We intend to cooperate with the investigation."

I wonder, might it relate to the same issues that Atricure recently endured?

"... under the new system, medical practitioners can choose among 1,170 coded descriptions that pinpoint such factors as the location and the device involved for each patient."

Or how about this reason:

"Hospitals, insurance companies and many doctors say the planned coding system is necessary to keep up with the host of new medical developments that emerge every year."

"Many" doctors? What the...? There is NO WAY "many" doctors are advocating for this. What does "many" mean in this context? While "many" can mean more than one doctor, I hardly think it means the majority. What doctor, in their right mind, wants to become a bureaucratic sycophant for the insurance industry?

Let's be clear here: this coding scheme is not sanctioned by "many" doctors except those that have crossed the health care employment boundary as hospital administrators.

This coding extravaganza will cost time, money and resources as physicians and their patients scramble to unlock the intricacies of the scheme to assure their patients receive health care. The system is sure to result in increased billing errors:

Some medical-industry officials also are concerned that consumers could see, at least initially, an increase in billing errors. That can lead, for example, to overcharging of patients, or an insurer denying payment for a claim because it was submitted with an incorrect code. Some officials also expect an increase in billing fraud and more delays in payments to doctors and consumers.

Monday, November 10, 2008

Carilion Clinic, as the system is now known, operates eight hospitals. They treat more than 500 Emergency Room visitors a day. The system employs more than 11,000 people.

It's a private, tax-exempt outfit. That enables Carilion to avoid $54 million a year in taxes.

Carilion says it spends $1.50 on community benefits for every dollar it receives in tax exemptions. With U.S. taxpayers already on the hook for more $700 billion in the financial bailout, how likely is a medical make-over? Carilion CEO Ed Murphy says he gets asked that a lot.

Want to know how to treat heart failure? It seems there are plenty of subspecialty groups within our specialty eager to offer guidelines on the proper management of various aspects of heart failure. Consider recommendations for treating heart failure from:

Can you venture any guess why so many organizations want to make sure we know how to treat heart failure? I wonder what it costs to create all these specialty societies and who funds their existence. Do all funds come from their members? Or might the pharmaceutical and device industries be supporting a significant portion of one or more of these societies?

Jupiter (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin), Astra-Zeneca's tour de force cholesterol-treatment trial, was released at the American Heart Association's national meeting yesterday and simultaneously published online yesterday. It's the talk of the town.

Especially in Boston.

That's where the study's lead investigator and the Brigham and Women's Hospital that holds patents on the c-reactive protein tests used to screen the 89,000-plus people for the 17,800 people enrolled in the trial are from. They're lovin' life right now.

Imagine inventing a test can be applied as a "screening test" on about 30 billion million people to find the 6 billionmillion or so people annually who would be benefitted by the prevention measure. Imagine making $1250 per year per person on the sale of your statin. Imagine that twenty five such individuals will have to be treated for five years with the statin to prevent one cardiovascular event.

Imagine.

This is not to say that the results of the trial are not impressive. To demonstrate a near 50 percent reduction in cardiovascular events in a carefully selected low-risk population for cardiovascular events is impressive. Really.

But at what price comes such preventative measures to our health care system?

If we assume that a 20-mg daily rosuvastatin (Crestor) tablet costs $107 per month to treat the average patient, and that twenty five patients have to be treated for five years to prevent one cardiovascular complication (and this does not include the annual liver function tests, the cholesterol tests, the C-reactive protein checks, etc), we begin to focus on an inevitable realization: that prevention is a remarkably expensive way to deal with our exploding health care costs.

For instance, if we assume that 25 people would have to be treated with Crestor for five years to prevent one cardiovacular event (as the study suggests), we can estimate the following back-of-the-envelope costs:

Number of people needing to be treated over 5 years to prevent one cardiovascular event: 25

TOTAL DOLLARS TO SAVE ONE CARDIOVASCULAR EVENT: $213,000

Applying these costs to the population that is thought to be at "risk" (some 6 to 10 billion million people), if every person were given this therapy, the cost to our health care system would implement this single prevention measure would amount to a whopping $51.12 trillion billion dollars over five years.*

Hey, if I owned stock in Astra Zeneca, I'd be "all in," too. But my simple calculations lead me to wonder if such prevention measures are the way to fix our current health care cost crisis.

I don't think so.

-Wes

*$213,000 per 25 people treated = $8,520 dollars per person treated over 5 years.6 billion million people treated for five years x $8,520 dollars per person = $51,120,000,000.

Sunday, November 09, 2008

Medicare offered its "Final Rule" for its 2009 Physician Fee Schedule for doctors recently. To see how this "Rule" applies to heart rhythm specialists is virtually impossible, thanks to the layers upon layers terms and specifications unique to only those who deal in such machinations. Here are a few such terms:

"CMS will continue using the “bottom-up” methodology to calculate Practice Expense RVUs."

"Practice Expense RVUs are calculated on the basis of a blend of RVUs"

"Harvard-valued codes"

"anti-markup rules"

"work GPCI floor"

And don't forget the "PE Database"

Is there any wonder that the guys who do the work are completely and utterly baffled by such a payment system? In every instance, the system obfuscates and confuses while supporting it's own network of highly-paid sycophants to decipher the hieroglyphics.

What an absolute and utter mess our system of physician payment has become. Even specialist societies, have to "continue to review the final rule and provide rate analysis of the impact on EP (electrophysiology) services in the weeks to come." (emphasis mine)

Most of us already know what the Robin Hoods of bureaucracy are going to do: steal from the rich (specialists) and give to the poor (generalists). After all, that's what "budget neutrality" is all about. But it's much easier to plug a number in to a computer formula than speak with people.

That's how people in the back boweries of government who don't deal directly with people work.

Friday, November 07, 2008

The general hospital is not viable, and most would collapse tomorrow in the absence of subsidies, restraints on competition and philanthropic life support. Trying to diagnose and treat any disorder that anyone might bring through their doors has forced them to separate their individual specialist physicians and their pieces of equipment (i.e., radiology and surgery suites). This is good for shuffling patients from one department to the next in a flexible way, but it means that hospitals lack the tight integration that allows them to address adequately the different needs of individual patients. This complexity drives up their overhead and has in many cases led to inconsistent quality and safety. This is why many patients now opt to get their knees, spines and cancer treated in specialty hospitals designed around a narrower set of procedures. Hospitals need to disrupt themselves, or be disrupted by others, to reduce cost and improve quality.

The fair market value of the facility is $53,734,360. ENH (now NorthShore) will provide approximately $54,000,000 to discharge Rush North Shore Medical Center’s indebtedness. In addition ENH (NorthShore) has committed to fund over $100 million in capital improvements at Rush North Shore Medical Center and will contribute $10 million to the Rush North Shore Foundation. The applicants have attested that all beds and services will not substantially change for at least 12 months following the completion of the proposed Exemption Application transaction, and there will be no change resulting in the restriction of patient admissions or reductions in access to care or a more restrictive charity care policy.

But not to be outdone, earlier this week Northwestern Memorial Healthcare (formerly affiliated with NorthShore) agreed on a whopping $400 million dollar purchase of Lake Forest Hospital only 6.2 miles from NorthShore's Highland Park Hospital:

The 215-bed Lake Forest Hospital has been viewed as a prime acquisition target amid a string of hospital deals in the northern suburbs.

The hospital, though profitable, faces big capital-spending needs in coming years, including an eventual overhaul or replacement of its aging facility for more than $400 million. CEO Thomas McAfee has been seeking a partner to help the 108-year-old hospital access capital.

The deal would mark a major strategic shift for Northwestern Memorial Healthcare, which operates the Streeterville hospital and affiliated physician groups but does not have much of a suburban presence.

Northwestern University’s medical school also was expected to seek another training site for medical students and residents after severing ties earlier this year with NorthShore University HealthSystem (formerly Evanston Northwestern Healthcare).

The statement said that adding Lake Forest to Northwestern Memorial would “accelerate the building of the pre-eminent academic medical center for Chicago, Lake County and the surrounding regions.”

Monday, November 03, 2008

In October, 2007, Medtronic issued one of the largest defibrillator lead advisory alerts for their popular and thin Model 6949 Sprint Fidelis lead due to the lead's higher-than-expected fracture rate. More recently, a software patch called a Lead Integrity Alert has been developed that can be uploaded into affected patients' defibrillators in hopes of improving the detection of lead fracture conditions. The software also automatically readjusts the settings of the defibrillator to make it less prone to deliver inappropriate shocks caused by lead failure.

Today in Circulation, the efficacy of this algorithm to avoid shocks was published from in vitro testing on leads returned to the manufacturer.* Real life effectivness of the algorithm has not been tested to date. So far, the algorithm theoretically shows improvement in avoiding unnecessary shocks:

To reduce inappropriate shocks, the lead-integrity algorithm increases the number of intervals to detect (NID) ventricular fibrillation when triggered. The lead-integrity algorithm was tested on data from 15,970 patients with Fidelis leads (including 121 with clinically diagnosed fractures) and 95 other fractured leads confirmed by analysis of returned product. The effect of the NID on inappropriate shocks was tested in 92 patients with 927 shocks caused by lead fracture. Increasing the NID reduced inappropriate shocks (P<0.0001). The lead-integrity algorithm provided at least a 3-day warning of inappropriate shocks in 76% (95% CI, 66 to 84) of patients versus 55% (95% CI, 43 to 64) for optimal impedance monitoring (P=0.007). Its positive predictive value was 72% for lead fractures and 81% for lead fractures or header-connector problems requiring surgical intervention. The false-positive rate was 1 per 372 patient-years of monitoring.

The distribution of the fractures reported was also interesting:

Of the 95 patients in the RPA (returned product analysis) group, 41 (43%) had fractures of the coil conductor to the tip electrode and 54 (57%) had fractures of the cable conductor to the ring electrode. Figure 5 shows that all coil fractures occurred at the anchor sleeve, whereas 52 of the cable fractures (96%) occurred distally or at the bifurcation/trifurcation.

We are about to see a rising number of patients with these leads enter the clinical arena as their ICD batteries reach their elective replacement indicators warning us of battery depletion. Recommendations from the company have so far been few, but most suggest a relatively conservative watch and wait approach. But when the patient's ICD pocket is opened for a battery change, the opportunity to place a new, non-recalled lead presents itself and should be considered (provided of course venous access still exists in which to place the new lead).

The difficult decision will come when there is no venous access in which to place a new lead from the same side as the existing defibrillator. Should we abandon the existing side and place an entirely new system on the opposite side with new, non-recalled leads? Should we send the patient for lead extraction and replacement? Or should we re-connect the old lead and hope for the best if no other option presents itself?

These are not easy decisions.

Patients with Sprint Fidelis leads should discuss what's involved with each of these scenarios with their doctors when the time comes to replace their defibrillator battery. Hopefully, we'll have additional trend data regarding lead survival on which to base future management recommendations. But until we do, battery changes in these patient's with Sprint Fidelis leads will be anything but routine.

Atricure, a Cincinnati-based company which manufactures a FDA 510K-approved curved clamp containing long electrodes that apply bipolar radiofrequency energy near the pulmonary veins to treat atrial fibrillation surgically, saw its stock plummet over 40% today on news the Justice Department is investigating it's marketing practices concerning off-label uses of its ablation system:

The letter also indicated that government investigators are examining whether AtriCure instructed hospitals to bill for surgical-ablation procedures using incorrect billing codes. The company made news of the probe public after the close of trading Friday.

AtriCure has faced past scrutiny over its ablation systems. In 2005 and 2006, The Wall Street Journal reported on the company's close ties with surgeons at the Cleveland Clinic and the University of Cincinnati. In at least two cases, those surgeons wrote favorable studies on the atrial-fibrillation treatment without disclosing their financial links to the company. The Cleveland Clinic had also invested in AtriCure.

AtriCure highlighted the positive studies in regulatory filings, calling them "independent" clinical studies that "demonstrate the efficacy, ease of use and safety of our system."

AtriCure's system for treating atrial fibrillation isn't specifically approved by the Food and Drug Administration for that use. Physicians are free to use FDA-approved medical devices in any way they see fit -- and many medical devices are used in this off-label fashion. But companies are barred from promoting unapproved uses of their products.

Although the specific terms of the Department of Justice's concerns have yet to be outlined publicly, one wonders of the other ablation devices in which the Atricure's 510K was predicated (the Medtronic Cardioblate Pen (K013392), the Boston Scientific Cobra Cardiac Surgical Probe (K013873), the CryoCath SurgiFrost Cryosurgical Device with FrostByte Clamp (K040690), the AFx Microwave Ablation System (K003978) and the Epicor Medical Ultracinch Tissue Ablation Device (K040641)) could also be investigated for similar concerns.

As such, devices that have received 510K approval by the FDA for "substantial equivalence" to existing devices but are promoted for off-label uses by doctor advocates seems like an area ripe for picking by the Department of Justice during this economic downturn and should send a chill down the back of device manufacturers and physician-advocates alike.

The budget deficit has reached $480bn this year, and some experts predict it will rise above $1 trillion by next year, when the cost of the bail-out is included.

This would represent half of all of federal spending, and put enormous pressure on interest rates and new spending programmes.

Most healthcare analysts believe that even without the deficit "there are no easy paths to financing universal coverage," as Professor Jonathan Oberlander of the University of North Carolina writes.

"All major financing options have serious political liabilities; they risk arousing either public opposition and anti-tax sentiment or stakeholder opposition," he adds.

He argues that neither plan is likely to generate enough cost savings to be self-funding, and that fiscal rules will make it hard to count the expiry of tax cuts as fresh income.

However, the key Democratic Senator in charge of such reform suggests that it would still proceed.

"While some suggest that the current economic situation might thwart efforts to overhaul America's healthcare system, I believe the state of the US economy makes the need for healthcare reform even more urgent," said Democratic Senator Max Baucus, chair of the Senate Finance Committee.

If others overseas can see the situation, why can't we?

Simple. In America, fixing our health care spending orgy will always be someone else's problem. It's just gotten too big for any one person to get their hands around it. So rather than face fiscal reality and all that that entails, we just keep adding hydrogen to our Healthcare Hindenburg.

Saturday, November 01, 2008

At our institution, we have a Patient's Bill of Rights that every patient is given when they are admitted to the hospital that includes, among other things, certain guarentees of the following:

Access to Care, Transfer, and Continuity of Care

Respect and Dignity

Confidentiality

Access to Your Medical Record

Access to Information About Your Condition, Treatment and Prognosis If Known

Communication with Visitors and People Outside the Hospital

Access to Informed Consent

Acceptance and Refusal of Treatment

Access to Pain Management

Access to Protective Services.

Would you also like included that "no law shall be passed that restricts a person's freedom of choice of private health care systems or private plans of any type" and "No law shall interfere with a person's right to pay directly for lawful medical services..."

(WSJ) Universal coverage plans, regulated by government, nearly always try to restrain costs by restricting the choices individual can make. This assumes a uniformity in the real-world of patients or the practice of medicine that simply doesn't exist, especially amid rapid developments in medical science. Who should decide -- the patient or a government treatment schedule -- whether a cancer sufferer should be able to try an experimental therapy or under what circumstances a senior citizen gets a hip replacement?

Government run health care proponents do not like this ballot initiative. In fact, as mentioned (subscription) in the Wall Street Journal today, opponents are spending four times as much as supporters in Arizona to defeat Proposition 101.

So if you were voting today, which would you choose, yeah or nay? Think about it. Review the pros and cons on the debate at the link above, then vote on my sidebar.

An elderly patient arrives at the Electrophysiology Lab to evacuate post-operative hematoma that started draining that morning. The patient without fever, chills and otherwise felt well. Surgery is arranged the same day to re-explore the wound and drain the hematoma, but because of the uncertainty of the presence of clinical infection, the decision was made to extract the defibrillator. IV antibiotics are initiated prior to surgery, intraoperative gram stain and cultures are sent, a drain is placed, and the wound closed with plans to continue IV antibiotics until cultures return.

Act One, Scene Two

The patient appears relieved the next morning, glad to know that the draining hematoma will not cause his ICD to become infected and is generally understanding of the circumstances. He as been on antibiotics and has is draining little from his wound. He'd like to convalesce at home. An attempt is made to contact social work to arrange home antibiotics, since he was otherwise stable and could follow up as an outpatient.

"Hello, Ms. Social Work?"

"Yes?"

"I have a patient who would like to continue his treatment at home, rather than just sit here in the hospital getting daily antibiotics. Clinically, he is very stable and I see no containdication to him receiving care at home."

(I hear typing on a computer in the background...)

"Oh, I'm sorry Dr. Fisher, we can't do that?"

"Why not?"

"Well, I see your patient is over 65 and home IV antibiotics in these circumstances are not covered by Medicare."

"Really?"

"Yes."

"Why is that? Isn't it more expensive (not to mention inconvenient) for my patient to remain hospitalized?"

"I'm not sure. But those are the rules."

"So my patient stays, get vital every shift, three hots and a cot, and festers at great expense to our system."

"Unless he wants to pay for it out of pocket..."

Act Two, Scene One

"Doctor, I think I have supplemental insurance for home health care. Maybe they could pay for my home antibioitics?"

"Really? Let me check with Ms. Social Work..."

(A call made ...)

"Well, I'm not sure if his particular policy convers this, I'm just not familiar with this coverage, but we'll check on it. It's hard to get things handled on the weekend, you know."

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About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.